VA Testimony of Thomas L. Garthwaite, MD before Congress on July 23, 1998

United States Department of Veterans Affairs

STATEMENT OF
THOMAS L. GARTHWAITE, M.D.
DEPUTY UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
ON MAINTAINING CAPACITY TO PROVIDE FOR THE SPECIALIZED
TREATMENT AND REHABILITATIVE NEEDS OF DISABLED VETERANS
BEFORE THE SUBCOMMITTEE ON HEALTH
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES

July 23, 1998

Mr. Chairman, I am pleased to be here to discuss VHA’s implementation of the legislation designed to ensure that the Department maintains the scope and quality of programs providing for the specialized treatment and rehabilitative needs of disabled veterans.

VHA's programs that meet the specialized needs of veterans help define the VA as a unique healthcare system for veterans. From VA’s inception, Congress has recognized our unique potential to serve as a national leader in the research and treatment of special disabilities. Due to the prevalence of certain chronic and disabling conditions among veterans, VA has developed strong expertise in certain specialized services. The VA programs and services for certain special disability groups -- veterans with Spinal Cord Dysfunction, Blindness, Traumatic Brain Injury, Amputation, Serious Mental Illness and Post Traumatic Stress Disorder -- are not widely available in the private sector. We are committed to meeting the care needs of veterans who have come to rely on VA for these specialized services.

Public Law 104-262 requires that we maintain our capacity to provide for the specialized treatment and rehabilitative needs of disabled veterans (including veterans with spinal cord dysfunction, blindness, amputations and mental illness) within distinct programs or facilities of the Department that are dedicated to the specialized needs of those veterans. The legislation requires ongoing monitoring of these special programs and requires reports to Congress. VA has submitted two reports to Congress, one in May 1997 and one in June 1998, concerning our capacity to meet these specialized needs of the veterans we serve.

Implementation of Public Law 104-262

We established an Eligibility Reform Steering Committee to manage implementation of the law. In addition, we established the Special Disability Programs Work Group to specifically address the requirement that we maintain capacity to provide specialized services to treat disabled veterans. The Work Group consulted with a number of stakeholders such as, National and State veterans’ service organizations, distinguished physicians and universities and colleges, other veterans organizations, VHA Networks and Facilities, and Special Program Managers. We also consulted with the Federal Advisory Committee on Prosthetics and Special Disabilities Programs and the Committee on Care of Severely Chronically Mentally Ill Veterans.

VA, in consultation with its stakeholders, defined various terms identified in the law, such as the conditions for which capacity must be maintained and definitions of how to measure capacity and access to care, as follows:

Six disabling conditions that require specialized treatment and rehabilitation are: spinal cord dysfunction, blindness, amputations, serious mental illness, Traumatic Brain Injury and Post Traumatic Stress Disorder. Homeless veterans and substance abusers, who are disabled due to mental illness, are included within the category of veterans disabled due to serious mental illness.
Capacity is measured by the number of unique individuals with the identified conditions treated within specialized bed sections and clinics and the dollars expended for their care. For veterans disabled by blindness and spinal cord dysfunction, capacity is also measured in terms of the number of specialized beds and FTEE.
Access is defined as timeliness.

Summary of Capacity Maintenance

The principal measure of capacity is the number of veterans treated. Nationally, the number of veterans treated in the 6 programs was maintained or increased for all categories, except amputation, which declined by 2%. Greater emphasis on preserving limbs and better management of veterans at risk has resulted in fewer amputations per year. Also, reduced expenditures for amputation, SMI and PTSD reflects an increase in efficiency, as more costly hospital inpatient treatment was replaced by outpatient care or by domiciliary care. Better care management and emphasis on primary care has also increased efficiency and reduced costs. In some cases, reduced demand, rather than reduced capacity, appears responsible for apparent capacity reductions. At many facilities, there have been fewer veterans seeking care, particularly Category C veterans. Some networks also explain that specialized capacity numbers give an incomplete picture because increasing numbers of patients with these conditions are appropriately maintained in primary care and general care programs. Attachment 1 illustrates workloads and dollars spent for SMI care in specialized programs as well as overall in all programs.

VA's performance for FY 1997 compared to FY 1996 for the specialized programs is summarized as follows:

Spinal Cord Dysfunction:

Nationally, the number of individuals treated for spinal cord dysfunction and dollars expended increased from FY 1996 to FY 1997, by 4% (patients) and 3% (dollars), respectively. The number of FTEE and operating beds decreased by 6% and 5%, respectively.

A noted improvement in timeliness from FY 1996 was achieved in FY 1997. Acute care improved from 41% to 91%, meeting the ‘timeliness for admission’ standard (one day), and routine care improved from 87% to 100%, meeting the ‘timeliness of appointments’ standard.

Blindness:

Nationally, the number of individuals treated for blindness and dollars expended each increased by more than 20% from FY 1996 to FY 1997. Similarly, the number of FTEE and operating beds increased by 5% and 1%, respectively.

In FY 1997, 11 of the 12 monthly waiting times increased over those of FY 1996, in the range of 1 to 8 weeks.
In FY 1997, up to 50% of veterans who used Blind Rehabilitation Outpatient Services did not require admission to the inpatient program. There are no comparable data for FY 1996.

Traumatic Brain Injury:

Nationally, from FY 1996 to FY 1997, the number of individuals treated for traumatic brain injury and dollars expended increased by 43% and 68%, respectively.

TBI waiting time has remained about the same as that of FY 1996, i.e., about 4 days for admission to TBI beds and about 7 days for outpatient care.

Amputation:

Nationally, the number of individuals treated for amputation in FY 1997 was 98% of the FY 1996 level, while expenditures decreased by 2% from the FY 1996 level.

Seriously Mentally Ill (SMI):

Nationally, the number of individuals treated for SMI increased by 1% from FY 1996 to FY 1997, while expenditures decreased by 3% from the FY 1996 level.

In general, there was about a 1% increase in FY 1997 over FY 1996 in the proportion of veterans receiving any psychiatric outpatient care within 30 days after discharge. This increase was accompanied by a 2-day decrease in the number of days from discharge to the first outpatient visit.

Substance Abuse (SMI Only):

Nationally, the number of individuals treated for substance abuse (SMI only) in FY 1997 was 98% of the FY 1996 level, while expenditures decreased by 20% from the FY 1996 level.

There was about a 3% increase in FY 1997 over FY 1996 in the proportion of veterans receiving any substance abuse outpatient care in the 30 days after discharge.

Homeless (SMI Only):

Nationally, the number of homeless (SMI only) individuals treated in FY 1997 was 100% of the FY 1996 level, while expenditures decreased by 3% from the FY 1996 level.

In general, the accessibility of psychiatric and substance abuse outpatient services to discharged homeless veterans increased in FY 1997 over FY 1996 in both general psychiatry and substance abuse programs, by about 3% and 5%, respectively. These increases were accompanied by a reduction in the waiting time for the initial outpatient visit by about 11 days for a psychiatric outpatient visit and by about 13 days for a substance abuse outpatient visit.

PTSD (SMI Only):

Nationally, the number of individuals treated for PTSD (SMI only) increased by 1% from FY 1996 to FY 1997, while expenditures decreased by 7% from the FY 1996 level.

PTSD (All):

Nationally, the number of individuals treated for PTSD (all) increased by 1% from FY 1996 to FY 1997, while expenditures decreased by 6% from the FY 1996 level.

There was about a 2% increase in FY 1997 over FY 1996 in the proportion of veterans receiving any psychiatric outpatient care in the 30 days after discharge. This was accompanied by a decrease of almost two days in the time it took from discharge to the first outpatient visit.

Plans for the Future

To ensure the delivery of excellent health care value, VHA is developing a system for monitoring that includes outcome measures. Outcomes are the outputs of the care process. Performance measurement in VHA is focusing on 5 domains of value that include access, cost, quality, customer/patient satisfaction, and functional status. Outcome measures, such as satisfaction with care and functional status, shift the focus of evaluation from resources, or the inputs of care, to the outputs of the health care process. Outcome assessments, adjusted for severity of illness, provide benchmarks for goal setting and information for administrators and policy makers for use in resource allocation decisions. Outcome measures will also facilitate comparisons among programs and facilities from year to year to assess the progress of special disability programs towards meeting the goals of providing high quality, optimally delivered medical care.

Focusing on outcomes (e.g., readmission rates, complications, functional status, continuity of care) rather than on inputs, (e.g., beds occupied, dollars spent) also provides an opportunity for innovations in service delivery and enhanced patient satisfaction.

Preliminary outcome measures have been identified for each of the special disability programs, but it will take 2 to 3 years to fully develop and collect data for all outcome measures. Patients treated and expenditures will be retained to assess capacity until refined outcome measures are available. These outcome measures will be used with the capacity measures, including number of unique individuals treated, to ensure that quality is maintained and to assess whether innovative approaches are effective.

Conclusion

I am pleased to report that VHA has maintained its national capacity to provide for the treatment and rehabilitation of the main classes of specially disabled veterans. While some subgroup and some network variation exists, we monitor these variations, and work towards ensuring equitable distribution of resources to provide equal access to all eligible veterans seeking care for their disabling conditions. This concludes my statement. I will be pleased to respond to your questions.

Attachment 1

Ratio of FY 1997 to FY 1996 for Seriously Mentally Ill Individuals Treated

and Dollars Spent

Specialized Care All Care

Disability Individuals Dollars Individuals Dollars

Seriously Mentally Ill 101% 97% 102% 103%

Substance Abuse 98% 80% 97% 97%

Homeless 100% 97% 100% 100%

PTSD (SMI Only) 101% 93% 103% 104%

PTSD 101% 94% 103% 105%

Although the indicated patient categories had "Specialized Care" dollar decreases ranging from 3% to 20%, each group of patients except Substance Abuse received at least as much total ("All") care in terms of both individuals and dollars in FY 1997 as in FY 1996. Despite a considerable shift to less-expensive outpatient care, the lone exception, Substance Abuse, had only minor reductions in "All" care for both individuals treated and dollar expenditures: the FY 1997/FY 1996 ratio was 97% for both measures.